Early Recognition and Management of Facial Cellulitis - Essay Example

Early Recognition and Management of Facial Cellulitis Facial cellulitis is the inflammation either due to infection/ abscesses in skin and tissues ofthe face which may include facial skin, periodontium, orbital/ periorbital area and ears, or it can result due to malignancy. In fact any breakage in the skin in the facial area can lead to access by bacteria which can cause infection and related pathophysiological cascade of events. Any acute inflammation is characterized by the classical symptoms of localized pain, swelling, tenderness, erythema and warmth, and in case of facial cellulitis this occurs in the skin and related soft tissues of the facial region (Micali G., et al, 2008). The facial region is a sensitive area with soft skin and delicate sensory organs like the eyes, ears, nose and the oral cavity which are highly vascular and innervated with sensory nerves. Although adequate defensive and immunological mechanisms are present to prevent the entry of pathogens in these areas, any break in the skin due to injury, insect bite, wounds or infection through the mucosa of skin, nose can provide the predisposing factors for cellulitis to set in, especially in immunocompromized individuals. Poor oral and skin hygiene is also one of the contributory factors for the precipitation of this condition. Neglect of minor infections in the area and lack of treatment can aggravate the condition when abscess formation and extensive infection sets in. An early diagnosis and treatment of the conditions is therefore absolutely essential. Certain patients are more prone to recurrent episodes of cellulitis due to pre-existing conditions such as diabetes, obesity, lymphatic obstruction, venous insufficiency, pressure ulcers and fungal infections of the dermis (Micali G., et al, 2008). Generally, odontogenic origin of the condition is common when infection occurs through the oral cavity via infection through the dental area where disruption of the periodontal mucosa is common due to mechanical in jury by rough food particles, unhygienic tooth picking or faulty dental procedures. The major reasons for cellulitis are infection by bacteria which have a propensity for skin and soft tissues. Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae and Pseudomonas aerogenosa are some of the common pathogenic bacteria which contribute in the occurrence of facial cellulitis (Micali G., et al, 2008; Atzori L., et al). These bacteria are usually susceptible to broad spectrum antibiotics and an early initiation of therapy can prevent complications. In untreated cases the infection can get generalized and spread to other systems of the body leading to systemic infection which can lead to a poor prognosis. Life threatening complications have also been reported as a result of oro-facial infections (Amponsah & Donkor, 2007). In four such cases, despite the use of antibiotics, acute spreading odontogenic disease had lead to systemic infection due to lack of surgical intervention. It was realized that optimization of pre-existing medical conditions prior to removal of the source of infection and drainage of pus is absolutely necessary to prevent such occurrences in addition to proper medical care in a specialized facility. Surgical removal of the focus of infection in the periodontium was considered a necessity. Improper management of such cases can lead to complications like cellulitis, mediastinitis, brain abscess, septicaemia and thromboembolism (Amponsah & Donkor, 2007). In addition to infectious causes of facial cellulitis, certain malignant tumours can also metastasize to the orbital area leading to periorbital cellulitis. Such cases are usually referred to the general physician rather than the ophthalmologist due to the varied aetiological factors. Post surgical infection and metastasis from distant tumours have generally been attributed for the occurrence of periorbital cellulitis. In one such case breast carcinoma in a woman had metastasized into the periorbital area (Stevens R. J. G., et al, 2003). Patients diagnosed with facial cellulitis should therefore be questioned and examined for the evidence of malignant disease in other systems of the body. Metastatic seeding of an organism can occur into the facial area from a distant focus of infection, especially in immunocompromized patients (Micali G., et al, 2008). Facial cellulitis is not a reportable disease and the frequency of its occurrence is limited to 2.46 cases per 100 person years in the United States (Micali G., et al, 2008). In the U.K. it accounts for 3% of emergency medical consultations. No age, sex or race related predilection has been encountered. The disease can be diagnosed by examination of the presented symptoms, evidence of chronic diseases like diabetes, hypertension and malignant disorders, history of recent surgical intervention in the facial area as well distant organs. The patient can be examined for tell tale symptoms like local inflammation, evidence of abscess, lymphangitis, regional lymphadenopathy, fever, local suppuration and necrosis (Micali G., et al, 2008). Microbiological investigations can lead to the isolation and characterization of the causative organism and susceptibility to antibiotics established by culture sensitivity tests. Treatment with antibiotics is usually successful in uncomplicated cases which have been diagnosed early and subjected to judicious and appropriate antibiotic therapy. Antibiotic therapy should be used in conjunction with minor surgical procedures (such as drainage of an abscess), which may be necessary for removing the focus of infection. The management of cellulitis depends upon the severity of symptoms as well the immune status of the patient. Mild cases are generally treated in the outpatient setting and oral antibiotics are usually prescribed depending upon their bactericidal spectrum directed against tackling the Streptococci/Staphylococci species in particular (Micali G., et al, 2008). Dicloxacillin, Flucloxacillin, third generation cephalosporins like Cephalexin/Cefuroxime, traditionally successful antibiotics like Cotrimoxazole, Erythromycin and those with a broad spectrum of activity, like Amoxycillin/Clavulanate are usually sufficient for the treatment of immunocompetent patients. Tetracyclines, Chloramphenicol and Aminoglycosides may be used in special cases where the aetiological agent is different or the culture sensitivity tests recommend the use of such agents. Local procedures such as cool saline dressings are also recommended for open lesions. Penicillin is a very effective agent but is usually avoided because of the propensity in some patients to exhibit hypersensitivity to the drug, which can be life threatening in some cases. Appropriate screening and pre treatment tests for hypersensitivity to Penicillin must be carried out before deciding on penicillin as the antibiotic of choice. The patient should be monitored for any adverse reactions in a hospital setting despite showing negative test for hypersensitivity. In immunocompromized patients and those suffering from concurrent diseases involving hepatic, renal or cardiac complications, hospitalization is recommended and appropriate antibiotics used by systemic administration (intra venous/ intra muscular routes), in a hospital setting. The common pitfalls in management can be the injudicious selection of the antibiotic agent by not ascertaining the pathogenic organism involved and its susceptibility to that particular drug. Not providing an adequate regimen of treatment can be another problem as the organism may develop resistance due to under dosing. Failure to use appropriate surgical intervention at the right time to eliminate the source of infection can be another area of vital importance. Differential diagnosis and management of the patients with pre existing medical conditions needs more attention than minor cases of facial cellulitis. References: Amponsah E.K. & Donkor P., (2007), Life-Threatening Oro-Facial Infections, Ghana Medical Journal, volume 41, Number 1 Atzori L., Ferreli C., Zucca M., Fanni D. and Aste N., Facial cellulitis associated withPseudomonas aeruginosa complicating ophthalmic herpes zoster, Dermatology Online Journal, Volume 10, Number 2, available online at: http://dermatology.cdlib.org/102/case_presentations/pseudomonas/atzori.html, Assessed March 2, 2009. Micali G., Dhawan V.K., Nasca Maria R., (2008), Cellulitis, Online article available at: http://emedicine.medscape.com/article/1053686-overview, Assessed March 2, 2009. Stevens R. J. G., Rusby J.E. and Graham M.D., (2003), Periorbital cellulitis with breast cancer, J R Soc Med ;96:292–294 Read More